Document 49556

Understanding the “notice of Medicare PreMiUM PayMent dUe” forM (cMs-500)
BiLLing notice date
The date the notice was selected for printing for this
billing period.
CMS–500 (09/11)
U.S. DEPARTMENT of hEALTh & hUMAN SERVICES
CENTERS foR MEDICARE & MEDICAID SERVICES (CMS)
notiCe of MediCare PreMiuM PayMent due
yoUr cLaiM nUMBer
Your Medicare claim number. *Please write this number on
your check or money order.
BiLLing inforMation
•Current amount due for Part A and/or Part B, *if
BILLING NoTICE DATE: mm/dd/yyyy
YoUR CLAIM NUMBER:
Use Visa/MasterCard/American Express/Discover or
make check/money order payable to “CMS Medicare
Insurance.” Send payment with the bottom portion of
this notice in the enclosed envelope to:
Medicare Premium Collection Center
P.o. Box 790355
St. Louis, Mo 63179-0355
this is the first billing you received, it may also include
premiums owed for previous months not already billed.
•Past due amount and period already billed for Part A
and/or Part B.
•Current amount and period due for Part D IRMAA.
•Past due amount and period already billed for Part
D IRMAA.
T
hospital
Medical
Insurance + Insurance + IRMAA
Part A
Part B
Part D
=
Total
Amount
Current amount due for Part A and/or Part B
mm/dd/yyyy – mm/dd/yyyy
$00.00
$00.00
$00.00
Past due amount for Part A and/or Part B
mm/dd/yyyy – mm/dd/yyyy
$00.00
$00.00
$00.00
$00.00
Current amount due for IRMAA Part D
mm/dd/yyyy – mm/dd/yyyy
$00.00
$00.00
$00.00
$00.00
Past due amount for IRMAA Part D
mm/dd/yyyy – mm/dd/yyyy
$00.00
$00.00
$00.00
$00.00
$00.00
ToTAL AMoUNT DUE:
Part B: TERMINATIoN DATE:
PAYMENT DUE BY: mm/dd/yyyy
on
$00.00
mm/dd/yyyy
To ensure timely processing, payments must be received by
this date will be included in your next notice.
p
p
$00.00
Part A: TERMINATIoN DATE:
Last payment received:
notice tyPe
Some people with Medicare are billed either monthly or
quarterly. If you are billed for Part A or IRMAA Part D, you will
be billed monthly. If this box says:
• first notice, it means payments are received timely or
this is your initial bill.
• second notice, it means a payment is late by at least
60 days.
• deLinqUent notice, it means a payment is late by at
least 90 days and you could lose your Medicare coverage.
• estate notice, it means a payment is due for a
deceased beneficiary.
• this is not a BiLL, it means a payment will be deducted
from your bank account (usually occurs on the 20th of the
month).
.
mm/dd/yyyy
. Any payments received after
See other Side for iMPortant inforMation
T
Please tear at dotted line and return bottom portion with payment
If your name or address has changed or is incorrect,
check here and complete the back of this notice.
aMoUnt Paid
Write in the exact amount of your check, money order, or
credit card payment.
If the person is deceased, check here.
p
CLAIM NUMBER:
Show claim number on check or money order.
Visa/Mastercard/aMerican exPress/discoVer
nUMBer
You may pay premiums with a Visa, Mastercard,
American Express or Discover credit card. To use
this option write in your credit card account number,
expiration date, and sign the form. Credit card payments
require a signature and must be returned in the envelope
provided.
$
AMoUNT PAID:
.
AMoUNT DUE: $
VISA/MASTERCARD/AMERICAN ExPRESS/DISCoVER NUMBER:
ExP. DATE:
SIGNATURE:
-
-
$00.00
DUE BY:
mm/dd/yyyy
Make check/money order payable to: CMS MediCare inSuranCe
C
Do NoT SEND CASh oR STAMPS.
SEND PAYMENT To:
Medicare PreMiuM collection center
P.o. Box 790355
St. louiS, Mo 63179-0355
p
(over)
CMS Product No. 11659 April 2013
Imp
iMPortant MediCare CuStoMer inforMation
•
If you do not pay your Part A or Part B premium, your Medicare insurance will be terminated. Even if your Medicare
insurance ends, you must still pay the total premium amount you owe. You can reapply for Medicare only during the
General Enrollment Period from January – March each year. If you reapply, your coverage will start on July 1 of the
year you reapply, and your payment amount may be higher because your coverage was interrupted.
•
This bill may include an Income Related Monthly Adjustment Amount (IRMAA) for Part B based on your income.
•
If you have questions about this notice, your Medicare Part A or Part B insurance, or the amount you have to pay,
please write or visit any Social Security office, or call 1-800-772-1213. TTY users should call 1-800-325-0778.
•
This bill may include an IRMAA for Part D based on your income. If you do not pay the IRMAA for Part D, you will
be disenrolled from your Part D prescription drug plan, even if it is part of your employer coverage or Medicare
Advantage plan. If your coverage is terminated and you re-enroll in Part D later, you will still have to pay any IRMAA
for Part D you owed. Also, your Part D plan monthly premium may be higher because your coverage was interrupted.
•
The IRMAA you pay for Part D may be higher than it was before because of new income or enrollment information
we received from Social Security or other agencies. If you have questions about your IRMAA Part D bill amount,
please call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
sPeciaL Messages
CMS uses this box to share important news about the
Medicare program or Medicare premiums. Please read
this information carefully each time you receive your
“Notice of Medicare Premium Payment Due.” Do not
write messages to CMS in this box.
Understanding
“The Notice
of Medicare
Premium
Payment Due”
Form
(CMS-500)
if your naMe or addreSS haS Changed or iS different froM the naMe or addreSS ShoWn on
the front of the forM, PLeaSe Print CorreCt inforMation BeLoW:
first
Name:
Last
C
Name:
Street
Number:
Street
Name:
P.o.
Box:
Apartment
Number:
City:
State:
MI:
Zip
Code:
–
Centers for Medicare & Medicaid Services